Cause and Effect in Modern Mental Healthcare

Jason Moheringer and I wrote this piece

For several years now, psychiatry, psychology, and the related mental health fields have been awaiting the release of the newest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) which is being published by the American Psychiatric Association later this month. This text forms the basis for diagnosis in mental health, as the DSM contains all of the diagnostic criteria, prognostic data, and treatment recommendations for each disorder. It strives to reflect the most up-to-date empirical and conceptual knowledge of mental illness and its many manifestations, and attempts to provide a foundation for consensus in the field.

Winnicott Reading Group

We are looking for a member to join us for a reading group of Donald Winnicott’s work. We have spent the last five months making our way through Bion’s corpus (which was fascinating). We’ll likely be spending this spring and summer making our way through selected articles from Winnicott’s original texts (including Maturational Processes and the Facilitating Environment, Playing and Reality and Through Paediatrics to Psychoanalysis). Preferably, we would like someone with a clinical background or interest in clinical work. We will likely divide our readings into six sections: Attachment, Emotional Development, Theory, Creativity, Diagnosis/Therapy and Technique. Let me know if you’re interested.

Social Control in Mental Health

This post is by Jason Moehringer, a doctoral student in clinical psychology at George Washington University

As part of my duties in a part-time job, I recently spent three days in a conference listening to experts and industry leaders discuss the intersection of technology and neuroscience. Specifically, so-called “brain training” as a primary or secondary treatment for chronic psychiatric disorders is being explored. The idea is that cognitive deficits (for the uninitiated: difficulties with concentration, organization, memory, attention, or emotional recognition and/or regulation) are frequently, if not always, an underlying component of psychopathology. These deficits derive from subtle brain dysfunction: their brains “misfire” or don’t have the proper “wiring.” So, treating these deficits (in this case, through remediation or skill-building provided by video games, ranging from Medal of Honor to Lumosity) will improve individual functioning and treatment outcome. Additionally, these improvements will be visible in changes in brain functioning or structure that can be seen in MRIs.

Alongside this, a growing trend in mental health treatment is to measure outcome based on how a patient’s functioning “improves.” In this context, “functioning” represents the idea that the individual or group in question can perform the activities necessary for living. So, a low-functioning individual may have trouble with personal hygiene, holding down a job, forming or maintaining relationships, or controlling their impulses (anything from inappropriate angry outbursts, to excessive shopping, to wearing tin-foil hats in public). As you might have guessed, a high-functioning individual will have little difficulty completing these activities.

As a clinician in training who works intensively with individuals who have moderate-to-severe personality and psychotic disorders – a population that was of particular interest to a subset of the attendees of this conference – I was hard-pressed to set aside my attention to the undercurrents of social control implicit in this approach to mental health treatment. Central to this unwitting adherence to conformity is the unquestioned fallacy of the emerging mainstream clinical phenomenon of “functioning.”

Forgiveness and Psychotherapy

I’ve been reading Fromm-Reichmann’s writings this weekend. She was a radical interpersonal psychoanalyst who was a trailblazer in the psychoanalytic treatment of schizophrenia. In one of her papers, she argued that it is mandatory that psychotherapists disabuse themselves of notions of social conformity or adjustment as being necessary for the psychotic individual’s recovery. She claims that the patient should have the right to choose to live the life they want and should not be forced to conform to society. In other words, she understood that the psychoanalyst ought to stay outside of the realm of ethics or social normalization precisely because it strips the patient of self-determination.

The amoral posture of psychoanalysis got me thinking about a notion that has long troubled me in my work as a psychologist, namely, forgiveness. I should clarify how I define forgiveness. From my perspective, forgiveness means the acceptance of the past event and the relinquishing of the negative affects (particularly rage and resentment) that accompany those memories. Generally, forgiveness also implies that the offended person expresses their forgiveness to the offender. As I’ve written elsewhere, a majority of my patients have experienced childhood adversity (neglect, psychological abuse, sexual abuse, physical abuse, etc.). [Parenthetically, I’ve become more and more convinced that the primary cause of mental illness is interpersonal trauma, which is unfortunately radical in this day and age of the brain.] Anyway, as the traumatized patient and I begin to delve into the trauma history the question of forgiveness invariably emerges. “Should I forgive him?”

Christianity and Atheism

Some friends and I are beginning a reading group on Jose Miranda’s Marx and the Bible. It’s a fascinating text that I’d highly recommend. I stumbled across this quote in the second chapter that I thought deserved some commentary.

“The reader is not going to find here another book on the “God is dead” theme or on the much-discussed “secularization,” nor the nth attempt to “recover” the atheists by making them see that although they might say that they deny the existence of God, deep down they accept it. We have had more than enough apologetics in recent centuries, and in my opinion the atheist has the right to be an atheist in peace without someone continually interpreting his position as undercover theism” (p. 35)

I couldn’t agree more. Although this text was written back in 1971, it is amazing how pertinent it is today. Over the last two years I’ve been avoiding theology (for professional and personal reasons), and I must say that I’ve becoming increasingly annoyed with Christian theology’s engagement with atheism. The Christian theologian’s relationship with atheists has always been a violent one. Too many theologians seem intent on appropriating atheism and somehow Christianizing and colonizing atheistic voices. For example, Westphal’s work on atheism was geared towards subjecting Christianity to the critiques of Marx, Nietzsche and Freud (the holy Trinity of atheism) and enabling Christians to use these critiques to strengthen their faith. It reminds me of the ways in which some evangelicals have courses in apologetics to prepare students for (imagined) hostile and secular university professors with the hopes that the young believer will be impenetrable to competing worldviews. I also wonder if postmodern theology’s project to integrate doubt and atheism into the Christian tradition is just one more attempt to domesticate atheistic critiques. Perhaps Miranda is right that we should leave the atheists alone because they are inevitably used as means by which Christianity attempts to convert non-Christians to the faith.

Psychosis, Truth and Psychotherapy

Currently, I’m making my way through Robert Whitaker’s Mad in America, which documents the treatment of psychotic individuals in America over the last three centuries. What is so startling is about the history of the treatment of psychotic individuals is how intent psychiatry has been on avoiding everything but psychological therapy as a means of treatment. For instance, we have tried the following bizarre and violent interventions: spinning chairs, hydrotherapy, lobotomies, dental surgery, electroshock, sterilization, bloodletting, insulin-treatments and neuroleptics. It seems important to consider why psychiatry has avoided speaking with psychotic individuals about their experiences. One of the major assumptions must be that psychotic speech is not true. From this perspective, psychosis does not reveal anything of relevance about the individual’s mind and their “symptoms” are absolute nonsense. Or, perhaps they will grant us that the “content” of the hallucinations or delusions might be relevant to the individual’s history but ultimately less important than addressing psychosis with a biological or medical intervention.

Professional Announcement

I wanted to share some exciting news with the AUFS community. Recently I’ve been absent from the blogosphere as I’ve been busy interviewing for post-docs. Well, the search is over and I’ve been blessed to be granted a two-year fellowship at Austen Riggs in Stockbridge, MA. Riggs is a fascinating psychiatric hospital that still prioritizes 4 times/weekly psychoanalytic psychotherapy as the primary clinical intervention. I’m very excited to have this opportunity. Not only will I be able to do research on psychosis but they will also provide a generous stipend for my personal two-year psychoanalysis. Thought I’d share the good news.

Sexual Violence: An American Problem

The Steubenville rape case along with the horrific gang rape in India has brought sexual violence to the media’s attention. Of course, we had GOP politicians who felt compelled by some ungodly force to speak about rape victims in demeaning and bizarre ways during the previous election. I know that my posts over the last six months have centered on the terribly depressing topic of sexual violence but I find that I am up to my ears in sexual violence as a soon-to-be-psychologist working in a public mental health setting. Last week I led a group with some women who had recently experienced sexual violence and they asked me a simple question: “Jeremy, you’re a guy. Do you know why guys think it’s OK to rape women?” This is a very difficult question and one that I had trouble answering. I responded with some vague statements about the ways in which our culture makes men feel entitled to have sex with women.

Domestic Violence and Psychology

As I’ve mentioned in a previous post, this year I’m spending my internship at a community mental health clinic in a rural setting. I have the opportunity to work with individuals who have been diagnosed with various disorders such as: schizophrenia, bipolar disorder, personality disorders, PTSD, depression, etc. Part of my work has also been conducting psychotherapy with individuals who are in abusive situations. On the weekend I work part-time at a local domestic violence shelter, which has been a real joy. Back in college I had the opportunity to work for two years at a domestic violence crisis center but I did not continue this work during graduate school. I am very excited to get back working in the field of domestic violence because it always been something that I’ve cared about both politically and personally. However, mental health and domestic violence sometimes have an antagonistic relationship. Many activists in domestic violence are skeptical of mental health because they fear that survivors of domestic violence are going to be pathologized and  that the reactionaries will use this to dismiss domestic violence. Some of this anxiety is understandable considering all of the idiots out there who have claimed that battered women (although not all survivors of domestic violence are women) want to be abused. Domestic violence workers counter that everybody is at risk for domestic violence (which is true) and that mental health professionals should recognize that the psychological and emotional issues of battered women are simply a product of the abusive situation.

This leads me to this weekend where I had the chance to read and reflect on David Celani’s text The Illusion of Love: Why the Battered Women Returns to Her Abuser (1994).

A Kleinian Appreciation

Over the last month I’ve been reading through Melanie Klein’s published works in Love, Guilt and Reparation and Other Works 1921-1945. Tonight I had the joy of reading her paper “Symposium on Child-Analysis” (1927) which is a response to Anna Freud’s critique of Klein’s play technique with children. I wanted to describe some of Klein’s intriguing arguments and then describe how Kleinians have a radically different way of approaching analysis for patients from all populations: children, adult neurotics and psychotics.